Provider Demographics
NPI:1790051738
Name:WOUND AND PODIATRY CENTER
Entity Type:Organization
Organization Name:WOUND AND PODIATRY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PERCY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM, CWS, CMET
Authorized Official - Phone:601-502-1100
Mailing Address - Street 1:1815 HOSPITAL DR
Mailing Address - Street 2:SUITE 434
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-3425
Mailing Address - Country:US
Mailing Address - Phone:601-405-5583
Mailing Address - Fax:601-502-0111
Practice Address - Street 1:1815 HOSPITAL DR
Practice Address - Street 2:SUITE 434
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-3425
Practice Address - Country:US
Practice Address - Phone:601-405-5583
Practice Address - Fax:601-502-0111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-23
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80107213ES0000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Multi-Specialty